​Kembara Xtra - Medicine - Chronic Cough

​Kembara Xtra - Medicine - Chronic Cough 
Introduction 

Adults with a cough that lasts longer than eight weeks are said to have a chronic cough.
Children who cough for longer than four weeks are considered to have a persistent cough.
Coughs that last between three and eight weeks are referred to as subacute.
Patients arrive out of anxiety about the underlying condition (such as cancer), annoyance, embarrassment, and hoarseness.
Gastrointestinal (GI), pulmonary systems affected

Incidence and prevalence in Epidemiology 

 Age distribution: all age groups
Males are more likely than females to seek medical care, according to the predominating sex ratio.
Incidence
Up to 10% of patients who report with chronic cough and up to 46% of patients who are referred to specialty cough clinics have persistent unexplained cough (1).
Prevalence
One of the most frequent causes for primary care visits is a chronic cough.

Pathophysiology and Etiology 
Depending on the illnesses involved and the findings, but most etiologies are connected to bronchial irritation. The following are frequent etiologies (representing >90% of cases) in nonsmokers:
- Upper airway cough syndrome (UACS) and other disorders of the upper respiratory tract, such as allergic and vasomotor rhinitis syndromes
- Postnasal drip and chronic rhinitis (allergic, nonallergic, chronic sinusitis, etc.)
- Asthma - Gastroesophageal reflux disease (GERD) - Postviral cough
Additional causes
Chronic smoking, exposure to smoke, or pollution; ACE inhibitors;
- Bronchiectasis - Aspiration - Infections (such as pertussis and TB)
eosinophilic bronchitis without asthma (NAEB)
Sleep apnea and cystic fibrosis
- Restrictory lung conditions
- Bronchogenic or laryngeal neoplasms
- Psychogenic (coughing habit)
A syndrome of cough with distinctive trigger symptoms that cannot be satisfactorily explained by other medical illnesses is known as cough hypersensitivity syndrome.

The most frequent causes of chronic cough in young children include asthma, protracted bacterial bronchitis, and UACS, which are different from those in older children and adults.


Risk Elements 

Smoking and lung disorders are the main causes of persistent cough, while other conditions may also be involved.

Accompanying Conditions 
Patients with UACS, asthma, and GERD may just have a chronic cough when they are diagnosed, as opposed to the typical symptoms that go along with those conditions.


Presenting History Some causes may be more likely as a result of the patient's age, concomitant signs and symptoms, medical history, medication history (e.g., ACE inhibitors), environmental and occupational exposures, the possibility for aspiration, and smoking history.
Hemoptysis or symptoms of systemic illness exclude empiric therapy. Cough diaries have not correlated well with objective assessments. The nature of the cough or description of the sputum quality is rarely helpful in predicting the underlying cause.


Clinical Examination Signs and symptoms vary depending on the underlying etiology; often, there is only a nonproductive cough and no other symptoms.
Potential UACS, sinusitis, GERD, congestive heart failure, and chronic stresses symptoms
Absence of additional symptoms or indicators of a certain ailment is not always beneficial. For instance, 5% of GERD patients have no other symptoms or signs and can have poor responses to empiric proton pump inhibitor (PPI) trials.


Diagnostic tests and laboratory results 
A chest x-ray (CXR) or other straightforward diagnostics, such as empiric therapy targeting a suspected underlying etiology, are frequently the first steps in an evaluation.
Only perform extensive testing if the history and physical recommend it.
Child Safety Considerations
Spirometry (if age-appropriate) and a foreign body assessment (CXR) should be performed on children with a persistent cough that is unresponsive to an inhaled -agonist and who do not have any overt stresses.

Initial examinations (lab, imaging)
Evaluation will be guided by the results of the thorough history and physical.
Peak flow analysis may be recommended.
CXR or B-type natriuretic peptide (BNP) may be recommended when neoplasm, heart failure, or infectious etiologies are being considered.
CXR may also be helpful when empiric therapy fails to work after an initial try.

Tests in the Future & Special Considerations
For instance:
- If you're thinking of having asthma, COPD, or restrictive lung disease: spirometry
- Sweat chloride testing if cystic fibrosis is suspected.
- Sputum for eosinophils and cytology if hypereosinophilic syndrome, TB, or cancer are suspected.
Consider a chest CT if there is an abnormal CXR, a suspected tumor, or an underlying pulmonary condition.
Take into account pulmonary consultation.
Consider visiting a specialized cough clinic, and suggest an endoscopy with a gastroenterologist.

Other/Diagnostic Procedures

If a diagnosis is made and first treatments are ineffective, more procedures can be thought about:
Pulmonary function testing; purified protein derivative (PPD) skin testing; allergen testing; a 24-hour esophageal pH monitor; a bronchoscopy if there is a history of hemoptysis or smoking with a normal CXR; an endoscopic or video fluoroscopic swallow evaluation; a barium esophagram; a sinus computed tomography; ambulatory cough monitoring; and a cough challenge with citric acid, caps

Management 
When treating a chronic cough, the most frequent causes (UACS, asthma, and GERD) should be targeted based on the clinical indications.

If allergy symptoms or postnasal drip are evident, an empiric trial of nasal steroids and/or antihistamines should be taken into consideration.
GERD should be taken into account as a potential cause when heartburn and regurgitation problems are present together.
Nonsedating antihistamines were not proven to be useful in lowering cough in patients with common cold-related cough.
Many people' coughs will go away once they stop smoking.
When necessary, individuals with intolerable cough should switch to ACE inhibitor medication. After ceasing ACE inhibitor therapy, the cough may go away for a few days or weeks.
Treat GERD and postnasal drip empirically.
Empiric PPIs are not advised for use in either children or adults without a GERD diagnosis.
For some adults, multimodal speech-language pathology therapy reduced the severity of their cough.
Try the most effective treatment for the one factor that is most likely to be the cause for a few weeks before looking for coexisting causes.

Medication Treatments should be targeted at the particular cause of the cough, such as nasal steroids, traditional antihistamines, antacids, bronchodilators, inhaled corticosteroids, PPIs, and antibiotics.

If the history and physical exam indicate GERD, you might wish to try empiric PPI therapy before undergoing additional diagnostic procedures.
The FDA released a public health recommendation indicating that children under the age of two should not be given over-the-counter cough and cold medications, including antitussives, expectorants, nasal decongestants, antihistamines, or combinations.
Manufacturers have since altered the labeling to read "do not use" for children under the age of 4. Routine empiric therapy of children with chronic cough with leukotriene receptor antagonists lacks evidence and cannot be advised, according to the FDA's 2017 contraindication to codeine for cough treatment in children under the age of 12.


Initial Line
Adults may use nasal steroids such as fluticasone, budesonide, and others, 1 spray BID, for individuals who have postnasal drip or allergic rhinitis symptoms, or an experimental dose of a PPI (omeprazole, among others), once day.
Next Line
The following antitussive medication has been used:
- For patients older than 10 years, administer Tessalon Perles (benzonatate) 100 to 200 mg PO TID as necessary (up to 600 mg/day).
Patients with refractory chronic cough were the subjects of a randomized, double-blind, placebo-controlled experiment to assess the efficacy of gabapentin. Compared to placebo, gabapentin showed enhanced cough-specific quality of life. 31% of people experienced nausea and tiredness. A 6-month treatment trial with a risk-benefit analysis is advised.
There is some effectiveness for treating cough in adults, but the evidence is limited, according to a comparative effectiveness analysis of 49 studies using popular opioid and nonanesthetic antitussives.

Studies examining the use of inhaled corticosteroids in patients with persistent cough who did not have other indications, such as asthma, did not consistently demonstrate benefits.


Concerning Referral Questions 
Evaluation by pulmonary, gastrointestinal, ear/nose/throat (ENT), and/or allergy experts may be beneficial for patients with chronic cough. Think about visiting a cough clinic.

Surgical Techniques 

Cough brought on by unresponsive GERD may respond well to fundoplication.


Take Action 
After the cough has subsided, think about reducing your medicine dosage gradually.
patient observation
It's important to follow up frequently to gauge the success of the therapy.
Avoiding booze, caffeine, nicotine, citrus, tomatoes, chocolate, and fatty meals may be beneficial for GERD patients.

 Ensure the patient that most persistent cough cases are not life-threatening and that the illness is typically treatable.
Suggest that coughing may need to be significantly reduced or eliminated for up to a month.
Because treatment is frequently empirical, be sure to prepare the patient for the likelihood of several diagnostic procedures and treatment plans.

Prognosis Using a systematic approach, >80% of patients can be accurately identified and treated.
Any cough can take weeks or months to go away, and how quickly it does so is highly dependent on how well the underlying reason is treated.


Reproductive: pneumothorax, laryngeal, or tracheobronchial trauma; respiratory: petechiae, purpura, disruption of surgical wounds; skin: petechiae, purpura; stress urinary incontinence; abdominal and intercostal muscle strain; GI: emesis, hemorrhage, herniation; neurological: dizziness, headache; seizures; other: poor quality of life